Towards a Feminist Global Health Policy: Power, intersectionality, and transformation

In the realm of global health policy, the intricacies of power dynamics and intersectionality have become increasingly evident. Structurally embedded power hierarchies constitute a significant concern in achieving health for all and demand transformational change. Adopting intersectional feminist approaches potentially mitigates health inequities through more inclusive and responsive health policies. While feminist approaches to foreign and development policies are receiving increasing attention, they are not accorded the importance they deserve in global health policy. This article presents a framework for a Feminist Global Health Policy (FGHP), outlines the objectives and underlying principles and identifies the actors responsible for its meaningful implementation. Recognising that power hierarchies and societal contexts inherently shape research, the proposed framework was developed via a participatory research approach that aligns with feminist principles. Three independent online focus groups were conducted between August and September 2022 with 11 participants affiliated to the global-academic or local-activist level and covering all WHO regions. The qualitative content analysis revealed that a FGHP must be centred on considerations of intersectionality, power and knowledge paradigms to present meaningful alternatives to the current structures. By balancing guiding principles with sensitivity for context-specific adaptations, the framework is designed to be applicable locally and globally, whilst its adoption is intended to advance health equity and reproductive justice, with communities and policymakers identified as the main actors. This study underscores the importance of dismantling power structures by fostering intersectional and participatory approaches for a more equitable global health landscape. The FGHP framework is intended to initiate debate among global health practitioners, policymakers, researchers and communities. Whilst an undeniably intricate and time-consuming process, continuous and collaborative work towards health equity is imperative to translate this vision into practice.

This subcode is interlinked with several codes.The great importance of privatisation and capitalism in global health and the explicit emphasis in the focus groups require a separate code.(For further distinction, please refer to the codes "Private sector" and "AAAQ of healthcare") "my immediate thought was that the biggest structural challenge in global health ehm is the role of the unregulated private sector ehm in the delivery of health care ehm and the corresponding myth that the private sector is more competent to deliver healthcare than the state" (FG1, JC, 217-21)

Structural inequalities
This subcode presents structural inequalities as the core of various challenges in global health.
This subcode is interlinked with several codes as structural inequalities constitute both the cause and consequence of further challenges.Since "Power regimes" determine "Structural inequalities", these codes are closely interrelated.However, to depict the structural causes and the resulting inequalities as fundamental challenge in global health, the subcode "Structural Inequalities" is applied."It's also about how can we dismantle this ehm this ehm this structure, this dominant structure that perpetuates inequality, and perpetuates ehm very oppressive, discriminating, ehm and repressive health policies."(FG1, CJ, 635-37)

AAAQ of healthcare
This subcode presents current challenges related to accessibility, availability, affordability, and quality of healthcare.
The code relates to the code "Enhanced health and healthcare", while emphasising the current problems and challenges instead of "We need to focus more on the accessibility, affordability, ehm equitability, and the availability of the services.

Lack of political will
This subcode presents the lack of political will and the preference to remain the status quo as a current challenge in global health.
This subcode is related to "Power regimes" and "National policymakers", but focus is on the explicit challenge that insufficient action is being taken and no CJe is sought.

Power regimes
This code is applied when references to power regimes are given.This includes the description of mainly problematic power hierarchies in societies and their effects as well as who holds power.It also entails an alternative perspective on why and how existing power regimes can be CJed.
The problem-related aspects indicate linkages to the codes "Privatisation & capitalism", "Structural inequalities" and "Lack of political will".The positively connotated text passages partly align with the codes "Meaningful engagement", "Community and civil society", "Equality", and "Radical transformation".The codes "Power regimes" and "Structural inequalities" are inherently related since power hierarchies create structural inequalities.
However, the application of "Power regime" as a code on its own can be justified because of its overall significance to this topic and its emphasis in the focus groups.Moreover, not all text passages are double coded because "Power regimes" does not necessarily relate to inequalities as this code also portrays alternatives and content about power itself.
"the point I had wanted to make really was picking up on the idea of power and, and the way that kind of power inequities are really baked into the global health architecture (laughs), and in part because of it's history, but also because of the way that we continue to perpetuate them either as individuals or institutions."(FG1, ER, 292-96)

Intersectionality
This code contains content related to intersectionality.It is The concept of intersectionality is closely intertwined with power.anything that we're going to do in terms of feminist policy ma/ne/ needs to take into account those things and needs to intervene at the point where we're not just thinking about ehm ehm women ehm as a as as a as a universal issue, but rather the intersectional issues of which kind of feminist policy we're talking about."(FG2, SM, 367-71)

Knowledge & discourse
In this code all statements or references to knowledge and discourse are considered.This implies the abstract, meta-level regarding questions about knowledge paradigms as well as the direct mentioning of knowledge, discourse, and language.
Questions around what counts as knowledge, who shapes the discourse, and who is listened to are related to the codes "Decoloniality", "Power regimes", and "Meaningful engagement".However, the code has its own focus and is emphasised in the focus groups.
"That our notions of excellence, and how we recognise excellence are so wedded to one particular way, predominantly kind of an Anglo-European approach or a Western approach of what evidence is ehm that we discard vast amounts of really important data when we're thinking about effects in health policy" (FG1, ER, 421-24)

Feminism itself
Aspects and issues concerning the feminist movement itself, including the existence of multiple feminisms, are entailed in this code.
The history of feminism and current challenges correspond with the codes "Power regimes" and "Intersectionality".However, the code has its own focus and "we'll be talking about feminist approaches, yeah, or approach.But I I think they are plural (ER nods heavily), and like for Europe and and North America it's very white dominated, you is emphasised in the focus groups.

Objectives & principles of FGHP
This main code entails the objectives of FGHP and the fundamental principles this policy is built on.

Enhanced health and healthcare
This subcode depicts the positive impact of a FGHP on health and healthcare and thus one of its main objectives.Parallels exist to the code "SDOH & contextualisation".However, the code has its own focus and is emphasised in the focus groups."Enhance health and healthcare" is the objective with "SDOH & contextualisation" rather depicting one component to achieve this.
"So I see that global health policy coming in to interact with the structures that are available in the country and influencing them to make sure that people have access to comprehensive and holistic health services."(FG3, LDA, 728-31)

Reproductive justice
This subcode is applied if reproductive justice is mentioned as a crucial objective and significant example of FGHP, including sexual and reproductive health and rights and bodily autonomy.Parallels exist to the codes "Enhanced health and healthcare", "Human rights", and "Equality".However, the code has its own focus and is emphasised in the focus groups.
"how do we place specifically sexual and reproductive health.How do we ehm give that control of the women so they can also control a little bit more about their lives, and their bodily autonomy."(FG2, OLU, 329-32)

Human rights
This subcode presents human rights as a central objective and principle of a feminist global health policy.
Human rights are closely related to the code "Equality".However, both concepts are important as independent codes.
"we have to think about ehm health being a right, and you know part of our human dignity and well-being" (FG1, CJ, 450-52)

Equality
This subcode presents equality as a major objective and fundamental principle for a feminist global health policy.
Parallels exist to the codes of "Human rights" and "Democracy", but the emphasis and different focus of each concept highlights the necessity of independent codes."I'm also looking at having, you know, a universal document that is going to be responding to the different needs of ehm, you know, ehm women and men in terms of equality and equity."(FG3, LDA, 273-75)

Democracy
References to democracy and its importance for FGHP as well as the threat of authoritarianism are compiled in this subcode.
Democracy entails the aspects of "Human rights", "Equality", and "Meaningful engagement".Therefore, strong linkages exist between these codes.However, it is important to mention democracy as a political system in addition to the components and principles it comprises.
"I think that political leaders who ehm are not held to democratic checks and balances are much more likely to enter into sweetheart deals with corporations to be seduced by corporate lobbying to be bought, and so the erosion of democracy and the erosion of political checks and balances, and the balance of power between the executive branch, the legislative branch, the judicial branch is so profoundly linked to ehm the kind of corporate capture of healthcare" (FG1

ANreness raising
This subcode presents the need of ANreness raising and related concepts as crucial for FGHP.
This code is linked to the codes "Meaningful engagement" and "Community & civil society".However, the code has its own focus and is emphasised in the focus groups.
"I do think that therefore, on a political level, ehm there needs to be this very in depth, sensitisation, progre/ ehm process, and also at the same time, and that's why I'm saying top-down and bottom-up needs to be linked, ehm in all these processes there needs to be ehm more participation of everyone in society."(FG3, AN, 368-71)

Education within the health system
This subcode is applied when the need to CJe the education within the health system and workforce is mentioned as an important component of FGHP.
This code is closely linked to "ANreness raising".However, "Education within the health system" refers explicitly to the training and content taught to the health workforce, while "ANreness raising" is less about training and more about sensitisation and consciousness-raising approaches in the broader society.
"another challenge that I would also like to touch upon is really the entire medical education and the way in which this education is given.So you know the principles of human rights, and all of that are not taught to medical practitioners" (FG1, SKY, 273-76)

Actors in FGHP
In this main code all relevant actors for a feminist global health policy are listed and information about their role and responsibility mentioned.

Community & civil society
This subcode compiles statements about the role of the community and civil society as actors in a feminist global health policy.
This code is related to the codes "Meaningful engagement", "ANreness raising", and "SDOH & contextualisation".However, focus is on the community and civil society as actors and their function for FGHP.
"for me it is really communitybased organisations (CJ and MM nod).Which have or follow feminist ideology and principles (JC nods).They, I feel, are key.Because they are the ones who are in the community."(FG1, SKY, 657-59)

National policymakers
This subcode compiles statements about the role of national policymakers and states as actors in a feminist global health policy.Parallels exist to the codes "Lack of political will", "Power regimes", and "Democracy".However, focus is on policymakers and states as "the states are the duty bearers" (FG1, CJ, 441-42) actors and their function for FGHP.

This
subcode compiles statements about the role of multilateral organisations as actors in a feminist global health policy.
Parallels exist to the code "Shift in funding".However, focus is multilateral organisations as actors and their function in FGHP, which extends beyond funding.
"I actually think everyone should be involved, and everyone can, and especially regarding institutions like UN Women and WHO.Those are the places where the resources sit as well.So, therefore, of course, ehm it should be also the responsibility of organisations like that to ehm to access their own resources, to then go on the national level and in the communities and work together."(FG3, AN, 649-53)

Academia
This subcode compiles statements about the role of academia as an actor in a feminist global health policy.
Due to its educational focus, this subcode is related to the codes "ANreness raising" and "Education within the health system", and also to "Intersectionality" and "Quantitative & biomedical focus".However, focus is on academia and universities as actors and their function for FGHP.
"what you talked about this already, neoliberal university where we have to put like where the quantity of output is more important than the quality of it (ER nods).Then there is no focus on the impactful CJe, there's no focus on the process and only on the output."(FG1, MM, 381-83)

Feminist economists
This subcode compiles statements about the role of This code is related to the code "Shift in funding", but the focus is on feminist economists as "but the lack of and to sort of equity informed, justiceinformed social regulation of that